A challenge confronting modern civilization is how to provide healthcare to all the members of a society. When stated in this way, the challenge transcends the issue of whether healthcare is a right or a privilege. It even exceeds the questions about how much healthcare and what quality of healthcare is a society to receive. Moreover, the challenge is a matter of economic reality—how can society afford universal healthcare coverage. When all is said and done, and there has been lots said and done with regard to this challenge, there are only a handful of consistencies that define the challenge—and it is these consistencies that lead us to the solution.
The following are the consistencies that frame the challenge:                Health Status of the Citizens—Obviously, a society with a population of healthy versus unhealthy people is better able to provide universal healthcare coverage.        Efficiency and Effectiveness of the Healthcare Delivery System—A society with a healthcare system that delivers high quality clinical outcomes for the least amount of resources is better able to provide universal healthcare coverage than a society with a healthcare system that is dysfunctional and delivers low quality clinical outcomes.        Affluence of the Society—Rich countries are better able to provide universal coverage to its citizens than poor countries. In fact, a country's affluence depends in large part on the health status of its citizens.        
Simply stated, a rich country with healthy people and an efficient healthcare delivery system is in a much better position to provide universal healthcare coverage than a poor country with unhealthy people and a dysfunctional healthcare system. It follows that a society increases its ability to provide universal coverage by improving its economy, its citizen's health status and its healthcare delivery system. So, the challenge can be distilled further to the objective of improving a society's economy, public health status and healthcare delivery system, and then maintaining these factors at levels that allow the society to afford universal healthcare coverage.
The United States presents an interesting combination of factors that complicate the challenge. The U.S. is an affluent country with declining public health, a largely dysfunctional healthcare delivery system, and since 2008, a struggling economy. Americans spend considerably more on healthcare per capita than citizens of any other developed country, and yet Americans' life expectancy and infant mortality rates rank toward the bottom of the list of these countries. For decades, the growth rate of healthcare expenditures in the U.S. has grown two to five times the rate the economy at large, consuming an ever increasing segment of the country's gross domestic production (GDP). Unlike other developed countries that provide government-sponsored universal healthcare coverage, the U.S. is the only country in which a majority of citizens receive healthcare coverage through their employers or by purchasing health insurance from a commercial insurer. Beginning in the 1990s and continuing to the present, the number of Americans without health insurance coverage or are under-insured has grown because it is becoming increasingly unaffordable. Current estimates place the number of uninsured at 45,000,000 to 47,000,000, which represents an all-time high of 17.1% of the U.S. population as of 2011. At the same time, the annual cost of healthcare coverage for a family of four exceeded $20,000 for the first time as of 2012.
Fueling this growth in healthcare costs and the uninsured is the declining healthcare status of Americans. The U.S. is far and away the most obese country on earth. According to the Center of Disease Control and Prevention (CDC) latest survey for 2010, 35.7% of American adults are obese. This compares with less than 15% in 1980, 24.2% for the next most obese country (Mexico), and 14.1% for all developed countries. Obesity is a well-known cause of all sorts of serious maladies that are expensive to treat such as diabetes, heart disease, hypertension, and metabolic disease. It is also a well-known fact that obesity can be prevented with better diet and exercise. Studies clearly show that preventing and reversing obesity along with other preventable health issues such as smoking, poor medication adherence and health illiteracy at a moderate level could save enough overall to provide funds to cover all the uninsured and then some.
Complicating matters is the fact that the supply of U.S. physicians to treat these diseases is also becoming an increasingly critical problem. The number of people filling medical school slots has not kept pace with the demand, especially for primary care physicians. Currently, the United States ranks 43rd in the world in the number of physicians per capita—and this shortage of physicians is occurring just as the “baby-boomer” generation begins to reach retirement age. The simple economic law of supply and demand will only add inflationary pressure on an already hyper-inflating situation.
Since the mid-1980s, several attempts have been made to control healthcare costs. The attempted reforms only temporarily slowed the escalation of healthcare costs during the mid to late 1990s, when health maintenance organizations (HMOs) incented medical service providers to control healthcare utilization. Successful lawsuits by patients that found HMOs rationed care and the threat of federal legislation (Patients' Bill of Rights) caused a dramatic decline in HMOs. Other approaches in which health plan sponsors (health insurance companies, self-insured employers or government programs) compensate medical service providers (principally physicians) to improve the quality and efficiency of healthcare quality in an attempt to bend the so-called cost curve include:                the pay-for-performance movement—a concept that assumed improved care quality would lead to cost containment;        accountable care organizations (ACOs)—a concept that essentially mirrors HMOs with a focus on improved quality to prevent the suggestion of rationed care;        patient-centered medical homes (PCHMs)—a concept that uses primary care providers and health information technology to coordinate better care;        the adoption of interconnected electronic health record (EHR) systems to help make healthcare more effective and efficient.        
Again, the reoccurring theme with each of these approaches involves the health plan sponsor compensating medical service providers to change their practice patterns in an attempt to bend the cost curve. The other characteristic common to these approaches is that patients (plan members) are not held accountable for their health behaviors, and therefore, are left out of the equation.
Another movement attempting to resolve the issue of healthcare coverage affordability involves approaches in which the plan sponsor financially rewards the patient to improve his/her health behaviors. Examples of this approach include:                wellness, prevention and care management programs—the patient (plan member) earns financial rewards for participating in these programs and/or for achieving specific health objectives;        high deductible consumer-driven health care plans—this approach includes health savings and retirement accounts that are intended to shift the financial responsibility for purchasing healthcare services to the plan member, thus incenting the plan member to be healthier and a discriminating healthcare shopper;        disease management—the plan sponsor hires nurses or coaches to encourage patients with chronic conditions to be compliant with recommended treatments;        population health management—similar to disease management, but includes other methods such as risk assessments, predictive modeling, wellness and prevention to address the complete population, not just chronically ill patients;        value-base benefit design (VBBD) or value-based insurance design (VBID)—designed to lower the financial barriers to patients with chronic conditions or use other financial incentives to encourage patient compliance.        
In addition to the plan sponsor financially rewarding plan members for participation in these programs or for accomplishing health objectives, the other characteristic common to these approaches is that medical service providers are excluded from the arrangement or have only a perfunctory role.
In essence, there have been two movements attempting to meet the challenge making universal healthcare coverage affordable—one in which plan sponsors financially incent medical service providers (service providers and healthcare service providers) to change their practice performance to the exclusion of the patient, and another in which the plan sponsor financial incents patients to improve their health behaviors to the exclusion of the medical service provider. After decades of effort and countless attempts, neither of these movements has succeeded in meeting the challenge.
In 2010, the federal government passed the Patient Protection and Affordable Care Act (PPACA or ACA) for the principal purpose of reducing the number of uninsured Americans. A secondary purpose of the law is to make healthcare less expensive to the country can afford to provide universal coverage. The PPACA's affordability provisions are primarily focused on improving the efficiency and effectiveness of the country's healthcare delivery system. Essentially nothing in the law addresses how to incept Americans to improve their health habits to prevent and reverse preventable conditions such as obesity. As a result, most experts agree that the law cannot effectively resolve healthcare affordability. Therefore, the goal of universal coverage cannot be attained or sustained without either further crippling the U.S. economy or by rationing care to Americans.
So back to the challenge, how can a society such as the U.S. provide healthcare cover to its entire population when the country can't effectively afford the cost of the current system with 17% of its people uninsured? How can people be attracted to the medical profession to alleviate the growing provider supply and demand issue when the economic outlook for the profession seems so gloomy?
The current invention is directed to improving the delivery of healthcare and health behaviors by creating a system of incentives that align the interests of healthcare's essential stakeholders—healthcare service providers (principally physicians), healthcare consumers/patients (health plan members), and health plan sponsors (health insurers, self-insured employers, health plans, and the government's Medicare and Medicaid programs) in a win-win-win arrangement. Unlike other cost containment methods that have consistently failed to recognize or accommodate for this fundamental success criterion of stakeholder alignment, the present invention provides an effective system to controlling healthcare costs by “triangulating” the interests of the service provider, the patient and the plan sponsor to improve the standard of care and encourage healthy behaviors, which leads to better health.
The present invention is directed to a method and information technology based system for simultaneously controlling cost by improving the delivery of healthcare related services by medical service providers and improving the health behaviors and status of patients (health plan members) by directing health plan sponsored financial rewards to both the healthcare service provider and the patient for enhancing communication and co-decision-making between medical service providers and patients, increasing the knowledge of the patient about how to self-manage his or her health, providing a system of “checks and balances” to measure and motivate patient and medical service provider adherence to accepted performance standards. As used herein the term “information technology based” means telephonic, Internet, web-based, or other computer based system for recording, storing, processing and communicating information.